MDH: Resident at St. Paul nursing home dies after ventilator stops for 39 minutes

MDH: Resident at St. Paul nursing home dies after ventilator stops for 39 minutes Photo: KSTP

January 03, 2019 04:28 PM

A resident at a St. Paul nursing home died when their ventilator stopped for 39 minutes before anyone responded, according to the Minnesota Department of Health.

The report from MDH states the resident died at Bethel Care Center on Aug. 19.

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The resident was admitted to the facility in June 2017 with diagnoses of chronic respiratory failure, ventilator dependence, tracheostomy and Parkinson's disease.

According to the MDH report, on Aug. 19, a nurse entered the resident's room when he heard the ventilator alarming. He found the resident unresponsive.


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The nurse said he "found the ventilator well connected, and he provided suctioning, but the resident remained unresponsive," according to the report. He also "initiated the emergency response system and provided respiratory support using a bag valve mask."

The nurse called 911, and when paramedics arrived, the resident was pronounced dead.

A review of the ventilator's data showed "a large leak or disconnection of the ventilator system," and that it alarmed for nearly 40 minutes, the MDH report states.

Multiple nurses interviewed by MDH said they were short-staffed the night of the resident's death because the facility had reduced staff on the ventilator unit.

The MDH found the Bethel Care Center neglectful because "the facility did not intervene" when the ventilator alarmed.

According to the MDH report, Bethel Care Center has since developed a staffing plan which added an additional associate to monitor patient ventilator alarms continuously.

The Care Center issued a statement on the matter, saying staff has taken "aggressive measures to bring the facility into full compliance since the deficiencies were cited last year."

The full statement reads as follows:

"Providing high-quality care and resident well-being are of utmost importance at Bethel Healthcare Community (“Bethel”). When an incident occurs, the team at Bethel follows established protocols through its Quality Assurance and Performance Improvement program to ensure the continued safety of our residents.  

"Staff has taken aggressive measures to bring the facility into full compliance since the deficiencies were cited last year. These included developing a plan of correction that was approved by the Minnesota Department of Health (“MDH”), providing additional training for staff and the implementation of a new staffing plan.  

"In November 2018, MDH revisited Bethel and found the community to be in substantial compliance. Bethel staff, with ongoing support from skilled clinical consultants, are dedicated to ensuring ongoing compliance and the delivery of specialized and compassionate care to our residents."  

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Anthony Brousseau

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